Go! Guide: Registration in the EHR

Transcription

1 Go! Guide: Registration in the EHR Introduction The Registration tab of the patient chart is where the patient s personal and demographic information such as address, date of birth, social security number, ethnicity, language, and other information is stored and kept up-to-date. This tab also includes information about the patient s emergency contact, parent or guardian, provider, and guarantor (the person responsible for the patient s account). In Neehr Perfect Go!, the Registration tab is located in the Accounts section. The Accounts section is generally locked (not accessible) for inpatient charts, but can be accessed for outpatient charts. In practice, medical office professionals are generally responsible for patient registration. Established patient registration is edited with current information each time the patient receives care at the facility. Brand new patients are added to the facility s EHR through a new patient registration prior to receiving medical care. It is important that the registration information is entered accurately and matches the patient s identity. Many EHRs, including Go!, now incorporate a photograph of the patient to assist with identity verification. It is also important that new registrations are entered carefully to avoid duplicate charts in the EHR. Having more than one chart for the same patient increases errors and causes inaccurate aggregate data reporting. Many EHRs, including Go!, have built-in duplicate checks, but if names are misspelled than the duplicate checks may not detect that a chart already exists. Additional resources Please refer to the Student Guide to Neehr Perfect Go! for information on logging in to Go! and launching the EHR for an activity. FAQs about registration 1. Where does the patient appear after I ve added the new registration? a. Locate the patient s chart again by selecting the specific activity where it was generated. Be sure to also resume the previous session in which you created the new registration. Accessing an existing registration in the EHR After launching the EHR for a portfolio or patient chart, select the Account section then the Registration tab: 1

2 If you see a padlock symbol next to Account then the section has been locked for that particular chart and may not be viewed or edited. In Neehr Perfect Go!, most inpatient charts have the Account section locked, but many outpatient charts may be edited. After selecting the Registration tab for an existing patient, the previously entered data will be displayed and can be reviewed. Scroll down to review all sections including Patient Information, Comments, Emergency Contact, Parent or Guardian Information, Provider Information, and Guarantor Information. Editing an existing registration in the EHR Follow the steps in the previous section to access the Registration tab for a specific patient. Then select Edit to update the patient s existing registration information. Note that the New 2

3 option is generally only used for adding brand new patients and should not be used for established patient charts. See next section. In Go!, any existing patient registration information may be edited. Fields with an asterisks (*) are required and must be populated. The Registration fields section of this guide describes the all of the fields in more detail. Select Cancel if you do not want your changes applied to the patient s registration. Otherwise, select Save after completing the edits. The patient s registration has now been updated to reflect the changes you implemented. Note that only you can see the changes and they do not impact other users in the EHR. These edits 3

4 are tracked in the EHR session and the corresponding Progress Report and can be submitted to your instructor for review. The Progress Report is found under Download Work for the specific EHR session (see Go! Guide to Completing and Submitting Work). Registering a new patient Some activities in Neehr Perfect Go! may require you to register a new patient into the EHR. In these cases, you will be brought to a blank chart after selecting Launch EHR for the particular activity. Your Student Portfolio may be another option for practicing new patient registration. Otherwise, if you are working with an established patient chart, you ll want to Edit existing information rather than creating a new registration (see previous section). When launching the chart for a new registration activity, you should automatically be brought to the Registration tab. If not, select the Accounts section, then the Registration tab. Select New to start a new registration. The following basic registration will appear: 4

5 Enter the following fields (those with asterisks (*) are required). The system s ability to detect a duplicate chart will be improved if more data is entered. First Name* Middle Name Last Name* Date of Birth (use format mm/dd/yyyy) Sex Then select Search to run a duplicate check. If no other patients exist with that same entered information, you ll see a message like this and may select Continue Registration. 5

6 If a duplicate is detected, you may review the potential duplicate chart(s) by clicking the patient name. Review the registration data and determine if it is a duplicate. If so, you may then choose to Edit the existing registration rather than create a new chart. If it is similar, but not a duplicate patient, select Cancel to exit the similar chart then select Contine Registration to proceed with registering the new patient. After selecting Continue Registration, you ll now complete the full registration for the patient. Data entered in the previous window will be populated already. 6

7 Include a photo of the patient by selecting Upload photo. Locate an image file (.jpg,.png, etc) and select Open. The photo will then appear. Populate the remaining registration fields. Be sure to scroll down beyond the Patient Information section to also complete the Comment, Emergency Contact, Parent or Guardian, and Guarantor sections. Fields with an asterisks (*) are required. Then select Save. See next section Registration fields for more details. The patient has now been registered. You may continue to add additional patient information into the chart, if applicable in the activity assigned by your instructor. Note: After registering a new patient, go back to the chart in the future by selecting the activity in which it was created then Resume the previous session. Submit your registration entry to your instructor by generating the Progress Report for the EHR Session. The Progress Report is found under Download Work for the specific EHR session (see Go! Guide to Completing and Submitting Work). Registration fields The following fields are included in the patient registration. See previous sections for additional information on adding a new registration or editing an existing registration. Those marked with an asterisks (*) are required (also listed in bold). Suffix: Select the suffix (i.e. Jr. Sr,etc) of the patient from a dropdown list, if applicable. Otherwise leave as default ( select a suffix ). First Name*: Type the patient s first name. This will auto-populate from the preliminary screen/duplicate check. 7

8 Last Name*: Type the patient s last name (family name). This will auto-populate from the preliminary screen/duplicate check. Middle Name or Initial: Type the patient s middle name or initial. Alias or Non-Legal Name: If the patient uses an alias or nickname, type it here. Sex*: Select Male or Female from the dropdown list. Date of Birth*: Enter the patient s date of birth using this format mm/dd/yyyy (i.e. 07/08/2001). Medical Record Number*: Enter a unique medical record number. Suggested format: MR#### (i.e. MR3478). SSN: Enter the patients social security number. Suggested format ###-##-#### (i.e ). Marital Status: Select the patient s legal marital status from the dropdown list. Language: Type the patient s primary language (i.e. Spanish). Patient Race/Ethnicity: Type the patient s race or ethnicity. Street Address*: Enter the patient s street address (house number and street name or PO Box). Apmt#: If the patient lives in an apartment or unit in a building, enter it here. City*: Enter the patient s city. State*: Select the patient s state from the dropdown list. Zip*: Enter the patient s 5-digit zip code or postal code. Enter the patient address. Home Phone*: Enter the patient s home phone number. If the patient does not have a home number, enter his or her cell number here since this field is required. Any format accepted. Suggested format: (###)###-####. Cell Phone: Enter the patient s cell phone number, if applicable. Employment Status*: Select the patient s current employment status from the dropdown list. Employer: Type the name of company or business where the patient works. Work Phone: Enter the patient s work phone number. 8

9 Occupation: Type the patient s job title. Comment Add patient notes below: Type any other relevant information about the patient such as the fact that the patient travels frequenty for business and is often away from home, the cell number is best. Emergency Contact Suffix: Select the suffix (i.e. Jr. Sr,etc) of the emergency contact from a dropdown list, if applicable. Otherwise leave as default (select a suffix). First Name: Type the first name of the emergency contact. Last Name: Type the last name of the emergency contact. Contact s Phone Number: Enter the primary phone number of the emergency contact. Street Address: Enter the street address of the emergency contact (house number and street name or PO Box). Apmt#: Enter the apartment or unit number, if applicable. City: Enter the emergency contact s city. State: Select the emergency contact s state from the dropdown list. Zip: Enter the emergency contact s 5-digit zip code or postal code. Parent or Guardian Information Parent or Legal Guardian of Patient: Select yes if the patient is under 18 years old or requires legal guardianship. Additional fields will appear. Otherwise, leave blank or select no. More than one parent or guardian may be listed. After entering the information for one parent or guardian, select Add a Parent or Guardian and another entry will appear. Relationship: Select the relationship to the patient from the dropdown list. Suffix: Select the suffix (i.e. Jr. Sr,etc) of the emergency contact from a dropdown list, if applicable. Otherwise leave as default (select a suffix). First Name: Type the first name of the parent or guardian. Last Name: Type the last name of the parent or guardian. 9

10 Street Address: Enter the street address of the parent or guardian (house number and street name or PO Box). Apmt#: Enter the apartment or unit number, if applicable. City: Enter the parent or guardian s city. State: Select the parent or guardian s state from the dropdown list. Zip: Enter the parent or guardian s 5-digit zip code or postal code. Phone Number: Enter the primary phone number of the parent or guardian. Provider Information Primary Care Provider: Select an existing provider from the dropdown menu to indicate who is the main provider responsible for the patient s care. It is not possible to enter another name. Referring Provider: Select a referring provider from the dropdown menu to indicate who directed the patient for care to the provider that rendered the services. It is not possible to enter another name. Rendering Provider: Select a rendering provider from the dropdown menu to indicate who provided the care to the patient. It is not possible to enter another name. Service Location: Select a clinic or hospital location from the dropdown menu to indicate where the patient was treated. Notes: Type any additional notes related to the patient s provider. Guarantor Information The guarantor of the patient is the person held accountable for the patient s bill. This is typically the patient unless the patient is a minor or an incapacitated adult. Relationship*: Select the guarantor s relationship to the patient from the dropdown list. Choose Self if the patient is responsible for their account. If Self is selected, the remaining guarator fields will populate with the patient s information. Otherwise, if another relationship is selected, complete the remaining fields (name and address) for the guarantor. See previous section listings if more information is needed about the fields. 10

11 Registration information on other areas of the chart The patient s registration information is also accessed on the Claims tab when adding a new claim. It is possible to update registration information via the Claims tab, if needed. See Go! Guide to Claims in the EHR. The Overview tab of the patient chart includes some patient information from the registration. It is not possible to edit patient information from the overview tab. You must go to the Registration tab under the Account section to do so. 11